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LETTERS Send your letters to the Editor, British Dental Journal, 64 Wimpole Street, London W1G 8YS. E-mail [email protected] Priority will be given to letters less than 500 words long. Authors must sign the letter, which may be edited for reasons of space. Staining from silver nitrate Sir, — We wish to highlight an unusual gingival aspect of both incisors. Other methods of achieving case where hypocalcified enamel became The patient was referred to a consultant haemostasis should be considered in stained with silver nitrate subsequent to in restorative dentistry whose those situations where the enamel its use to achieve haemostasis during soft examination revealed that the enamel at structure may have been compromised. tissue biopsy. the gingival aspects was very thin and Alternatively, physical protective barriers A 16 year old girl was referred by her decalcified, consistent with tooth wear such as dental rubber dam could be used GDP for the excision of an unsightly due to erosion. The staining was attributed to protect the dental hard tissues from papillomatous swelling in the region of to the uptake of silver nitrate by the staining. the interdental papilla between the right porous enamel at the cervical margins Z. Sadiq, C. Moss and J. Stocker premaxillary incisors, which developed adjacent to the biopsy site. The patient Peterborough following a course of orthodontic underwent scaling, polishing and micro treatment. Examination revealed a 6 mm abrasion which produced some papillomatous type lesion with a improvement in appearance of the strawberry-like appearance at the dental affected teeth. The patient was also papilla between the right premaxillary offered further treatment including air incisors. The lesion was mobile with no abrasion and veneers. Although the use of evidence of periodontal pocketing. The silver nitrate is a method of achieving patient underwent excisional biopsy of haemostasis, this case highlights a the lesion under local anaesthesia limitation of its use. A careful history, outpatient care; during the procedure a examination and assessment of enamel silver nitrate stick was used to achieve status is important before deciding to use haemostasis. The patient subsequently chemical agents to achieve haemostasis in Fig 1. Staining in the upper central and developed a bluish staining (fig 1) at the procedures on the adjacent tissues. lateral caused by the silver nitrate. Mercury amalgam-gold The amalgam and gold surfaces in the The key conclusion of both papers, i.e. patient’s mouth are all of different ages that restorative interventions provided crown interaction and may therefore be at least subtly within the General Dental Services in the Sir, — A patient attended surgery recently different in their composition. The UK do not appear to influence outcome, is for a routine inspection. A battery amalgam adjacent to the affected gold hugely disappointing, but sadly comes as driven/electric toothbrush was advised in crown has been replaced with a gold inlay little surprise to those within the Specialty order to reduce gingival recession and with no further effect to the gold crown. I of Paediatric Dentistry. That effective abrasion caused through too vigorous would be interested to hear whether restorative interventions for primary teeth manual toothbrushing. Accordingly, the anybody else has come across this exist is not in doubt. Stainless steel patient bought one and used just a few phenomenon, and also for any speculative crowns, for example, have demonstrated hours after inspection. explanations. There is also a toxological excellent longevity in a number of On self examination, the patient noticed dimension to the observation. A few free studies.3 The vital pulpotomy technique that a gold crown in the lower right standing milligrams of the amalgam has achieved over 90% success in virtually quadrant, which is adjacent to a silver filling and a scraping of the dull coat all studies that have investigated its amalgam, had lost its bright, highly deposit from the gold crown are available efficacy.4,5 In addition, contrary to the polished surface, and acquired a to interested parties for analysis. studies currently being discussed, there is tenacious, greyish appearance, akin to D. M. Cowen some evidence that a small minority of ‘brushed’ stainless steel. No such change Keighley practitioners within the GDS do achieve a occurred on any other gold crowns in the good outcome.6 However, the patient’s mouth even though they are fundamental question is this: why are the adjacent to other silver amalgams. On Paediatric dentistry levels of success reported in studies of polishing the affected gold crown, the Sir, — The recent papers investigating the individual techniques not being translated original yellow surface was exposed, but outcome of dental caries in primary molars by the majority of primary care appeared duller. We could speculate that raise important and fundamental questions practitioners into effective treatment the new electric tooth brush had possibly about dental services for children in the outcomes for children in the UK? liberated something from the silver United Kingdom and the authors are to be There can be little doubt that the amalgam, which was subsequently taken congratulated for taking the first steps authors’ assertion that ‘effective methods up by the gold crown; it was also noted into this potentially controversial area.1,2 I of preventing dental caries at the that the amalgam in question had have been asked to co-ordinate this individual and public health levels need to subsequently taken up a rather pitted consensus response on behalf of the be expanded’ is correct. However, in spite almost granular appearance. Consultants in Paediatric Dentistry Group. of considerable efforts to promote the BRITISH DENTAL JOURNAL VOLUME 193. NO. 6 SEPTEMBER 28 2002 299 LETTERS preventive message, dental caries is still at challenging questions: accidental trauma to the anterior 2/3rds of epidemic proportions in the young the tongue or lip either by the dentist or • Why is the success of restorative inter- children of our country and there has been the patient. The patient would also be ventions currently provided in the UK little change in its prevalence in the socially incapacitated after leaving the GDS apparently so poor when effective, primary dentition for nearly two decades. surgery. The use of rubber dam is the best evidence-based interventions are avail- In many parts of the country around way of protecting the patient from soft able? 50% or more of 5 year-old children have tissue damage, inhalation/ingestion of • Is the GDS the best place to provide den- dental caries experience, and, on average, debris and instruments and the tal treatment for a young child with those with decay have around four or unnecessary over-administration of drugs. caries or would improved access to spe- more decayed teeth by this age.7 The It also enhances the field of operation thus cialist paediatric dentistry services lead second of the two studies in question improving the quality of work done. Other to better outcomes? reinforces the findings of a previous study systems, such as Aqua-Vac, exist to • Does our current approach to DGA and which demonstrated that dental caries in overcome the difficulties described if the conscious sedation services for children children is associated with a high placement of rubber dam is impossible. need to be re-considered? morbidity.8 It is also important to P. L. V. Martin recognise that these studies employ design Now that the anaesthetic safety issues London features (i.e. retrospective record analysis) related to the delivery of conscious seda- which are likely to result in an tion and DGA have been fully addressed, Ethical selling undercounting of adverse events. The full what can be done to improve the quality of Sir, — The leader entitled Ethical selling - picture may be significantly worse. the dental care provided at the time of what is it? (BDJ 2002; 192: 423) There is clearly an urgent need to ensure these interventions, hence improving out- highlighted many of the qualms that that, where preventive strategies have come and reducing the need for repeat pro- practitioners have when broaching the failed to stop the development of clinical cedures? It is imperative that we respond to question of selling specific clinical disease, effective treatment interventions these challenges without delay. services. The final paragraph, which you are available. One potential route for S. A. Fayle quite rightly identified as crucial, raised primary care dentists is to refer young Leeds the question of what patients want and children with caries to a specialist centre. what they need not always being the same However, following implementation of the 1. Tickle M, Milsom K M, King D, Keamey-Mitchell P, thing. Once patients have been given Blinkhorn A S. The fate of carious primary teeth recommendations of the joint report of the among children regularly attending the General treatment options they often ask ‘is this CMO and CDO on the provision of dental Dental Service. Br Dent J 2002; 192: 2 19-223. treatment necessary?’ An explanation I general anaesthesia (DGA) services, 2. Milsom K M, Tickle M, Blinkhorn A S. Dental pain and give is that if the patient wants the end dental treatment of young children attending the paediatric dentistry services in many parts General Dental Service. Br Dent J 2002; 192: 280-284. result then the treatment is necessary. If, of the country are already under severe 3. Fayle S A. Faculty of Dental Surgery, Royal College of on the other hand, the patient does not pressure.9 While there has been a Surgeons. UK National Clinical Guidelines in want the end result, then the treatment is centrally driven shift of service provision Paediatric Dentistry. Stainless steel preformed crowns unnecessary. I suggest it is therefore the for primary molars.

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